Hall, Franklin rt.-m ,, fl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t2r This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
` Town
Dist. Nc .` TCounty/. VilIage..
or City � (If city,give eet address)
Name of decease 4/� C-0—., /-)y ��v
' le, married, widowed,
Sex Color../ Ivo'rced (writ the word) Date of Deat ... -2. 19.'W.
Ages/ Years...5 Months 4._,...Days Birthplace. .
Cause of Death, . ,
Certificate was signed by.. �-� _ - M.D.
.�.. .
Address ti,,, o-- ��
Place of Burial (or Removal) `Z-S*,-.r---0. , — .110'C
(If body is to be to arily held.fill in space later)
Cemetery Date of Buri 19..ite4
(If body is to be temporarily held, fill i ce later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numb , and on the basis ereof I HEREBY GRANT A PERMIT r
to.
_ =�`
(N a (Address)
top -ai to hold temporar' and... the body.
( dert o erson having charge of corpse) r, ve, r herwise disooae of[state how])
rate'' % 19.E f 2--- (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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